Form Uhss 2.1-1 - Application For Admission
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1
2
3Application for Admission
To Residential Health Care Facilities in
St. Lawrence County
General I nform ation
Name
Phone
Legal Address
Present Location
Date of Birth
Social Security #
Married
Single
Widowed
Separated
Divorced
Spouse or Significant Other’s Name
Sex
Male
Female
Place of Birth
U.S. Citizen Yes
No
Father and Mother’s Names
Religion (optional)
Occupation:
Personal Physician
Type of Admission:
Long Term Care
Short Term Rehabilitation
Relatives/ Friends To Be Notified I n Em ergency
Name
Name
Address
Address
City ______________________State____ Zip_________
City ______________________State____ Zip_________
Relationship
Relationship
Home #
Work #
Home #
Work #
Cell # _________________ Email
Cell # _________________ Email
Advance Directives
Health Care Proxy
Yes No
Body Donor
Yes No
Living Will
Yes No
Organ Tissue Donor
Yes No
DNR Order
Yes No
MOLST Form
Yes No
P ersonal P references
Maplewood Healthcare and Rehabilitation Center
St. Regis Nursing Home
89 Grove Street
(dba for United Helpers Canton Nursing Home, Inc.)
205 State St. Road
Massena, New York 13662
Canton, New York 13617
Clifton Fine Hospital Long Term Care
RiverLedge Healthcare and Rehabilitation Center
1014 Oswegatchie Trail
(dba for United Helpers Nursing Home, Inc.)
PO Box 10
8101 SH 68
Star Lake, NY 13690
Ogdensburg, New York 13669
Highland Nursing Home
St. Joseph’s Home
182 Highland Road
950 Linden Street
Massena, New York 13662
Ogdensburg, New York 13669
01/19/15
Form UHSS 2.1-1
Page 1 of 3
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Parent category: Medical